Failure to Investigate and Respond to Allegations of Abuse and Drug Use
Penalty
Summary
The facility failed to thoroughly investigate and respond to allegations of abuse, neglect, and exploitation for two residents. In the first case, a male resident with dementia and a history of sexually inappropriate behaviors was admitted without a care plan addressing these behaviors. Despite documentation from a previous facility recommending placement in a male-only secured unit due to sexual aggression, the facility did not implement appropriate interventions upon admission. The resident later inappropriately touched a student visitor during an activity, but the incident was not fully investigated or reported to the state agency. Staff and other residents reported ongoing sexually inappropriate behaviors, and the resident was only placed on Q15-minute monitoring after the incident. The Administrator reviewed camera footage but did not see conclusive evidence and therefore did not proceed with a full investigation or report the incident, despite policy requirements. In the second case, another male resident with multiple diagnoses, including bipolar disorder and legal blindness, was suspected of bringing drugs into the facility and selling them to other residents. The resident was found exhibiting signs of overdose and was sent to the hospital, where he tested positive for marijuana. Despite prior knowledge of the resident's behavior and reports from staff and other residents about drug use in the facility, there was no care plan addressing substance abuse. The facility did not initiate a thorough investigation or report the incident to the state agency. The Administrator and DON were aware of ongoing concerns about drug use, including the smell of marijuana during smoke breaks and packages suspected of containing THC, but did not take investigative or reporting actions. The facility's policy required investigation and reporting of all allegations of abuse, neglect, and exploitation, but these procedures were not followed in either case. Staff were not in-serviced on recognizing or reporting signs of drug use after the incidents, and there was no evidence of comprehensive investigations into the allegations. The lack of timely and thorough investigation and failure to implement effective interventions placed all residents at increased risk for abuse and neglect, as directly stated in the report.